Sudbury Care Homes Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents had been documented. Completed forms included information on what had happened, initial actions taken and any follow up actions. Post accident monitoring had been completed, for example, when a person had a fall in the community the registered manager explained they ensure people are involved in how to prevent such incidents going forward. This was completed by asking the person who they wish to be supported on uneven pavements, the outcome was the person chose to link arms with staff, so they felt better supported and reducing the risk of a fall.

The provider collated any complaints and compliments within a dedicated file. No recent complaints had been received. The registered manager told us they tried to address minor issues quickly, to prevent them escalating into formal complaints. A family member we spoke with told us, “Any issues we have we know to contact the manager or indeed any of the staff, we know it will be dealt with in a timely manner, communication with the provider is really good.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There were thorough safeguarding policies, procedures, and processes that followed current legislation. The systems demonstrated safety concerns which were reported to the registered manager, recorded, monitored frequently and raised with appropriate bodies in a timely manner. Where appropriate, people and those important to them were involved in this process and informed about what action would be taken to keep people safe. A person told us, “I like living here, I feel safe and happy.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives said they felt very safe using the service, and the support they received was good. They told us staff supporting people understood how to keep them safe. A relative said, “[Person using the service] has lived there for many years, we know the registered manager and team so well and feel very well supported.” People and their relatives were confident in raising concerns, received a prompt response, and if they felt there were safety issues, they were appropriately investigated, and they received an outcome. The impact of this was that people were reassured that they received care that would keep them safe, and any concerns about their safety would be fully investigated and rectified.

Staff we spoke with showed a thorough knowledge of safeguarding and were confident in reporting procedures. They demonstrated a clear understanding of Making Safeguarding Personal (MSP) principles, placing emphasis on individual outcomes and supporting people’s choices. A staff member explained, “We are a small team with a registered manager that is very proactive and always ensures that the people we support and their choices and safety come first. We look at all areas of support holistically which gives us a good opportunity to ensure the best outcome for people.”

The registered manager had ensured they were working within the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. At the time of our inspection people had capacity to make decisions.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The care plans and risk assessments we reviewed included people’s perspectives on how risks should be managed, with decisions made collectively to promote independence, choice, and control.

Staff we spoke with demonstrated a clear understanding of the procedures for recording and reporting incidents. Staff were able to respond to risks and had the right systems in place to ensure timely and accurate documentation. This approach supported a safe environment where risks are actively monitored and addressed. 

The provider had a robust accident and incident reporting policy in place, and this was accessible to all staff. The registered manager completed regular audits and care plans were updated if new risks were identified, this involved the people supported and the team, so all care and associated risks were looked at in a holistic way and person centred way.

Relatives also spoke positively about the service’s approach to risk. A relative commented, “They enable people to do lots of things in and outside of the home which is really positive.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was clean welcoming, and in good repair. Regular maintenance activities were undertaken, such as safety checks on equipment, repairs to fixtures and fittings, and updates to communal spaces.

The service had external contractors who were responsible for carrying out annual safety checks within the premises. This included gas testing and servicing, electrical checks, and fire safety testing.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staff retention was positive for the service with the team working together for many years. This meant that people supported knew the team very well and vice versa. Staff were involved in champion roles , this meant that staff got to lead on areas they wanted to learn more about , for example one staff member was the champion for supporting people with behaviours that challenge, the staff member we spoke to told us, “Leading on this area means that I am able to learn more how best to support people with challenges they may face and how best we can support them, the role involves researching information and undertaking training, sharing the learning with the team so we ensure consistency for the people we support when they need it.”

Staffing levels meant people were supported to pursue their interests and hobbies when they wished. People discussed the activities they would like to do during meetings. The activities included Zumba classes and swimming.

The staff recruitment process was thorough, and records demonstrated it was followed, and regularly reviewed. Staff received comprehensive training that was based on the Skills for Care 'Common induction standards. They form part of the Care Certificate which is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social sectors. Disciplinary and capability processes were fair and regularly reviewed to ensure there was no disadvantage based on any specific protected equality characteristics. The processes enabled staff to receive appropriate, comprehensive training that was relevant to their role and enabled them to meet people’s needs.

Supervision records confirmed that staff had regular 1 to 1 meetings with management to support professional development and identify further learning needs. Systems monitored training and supervision, ensuring staff remained up to date and equipped to deliver safe, effective, and person-centred care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The systems and training were efficient and maximised infection control which ensured a clean, hygienic environment for people to live and staff to work in. We observed the home to be clean, tidy and hygienic.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff were trained and assessed as competent to manage and administer medicines. Medicines were stored securely and at the correct temperature which was checked daily. MAR charts included people’s photographs to support identification and reduce risk of error.

People received their medicines as prescribed. There were no errors identified in the medicines check we completed. People who had ‘as required’ medicines had clear protocols for staff to follow and guidance if something went wrong, these protocols were signed off by people’s GP. Risk assessments were completed to determine the level of support each person required, and this was reviewed regularly to promote independence.

The registered manager had a staff member assigned who was the medicine champion, they were very knowledgeable and proud of their role, this included building a really positive professional relationship with the local GP.

The registered manager regularly audited medicines regularly to ensure they had management oversight.